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Annals of Gastroenterology and the Digestive System

Open Access | Review Article

Development of radiotherapy for liver cancer

Nobuyoshi Fukumitsu1*; Masayuki Mima1; Yusuke Demizu1; Takeshi Suzuki2; Toshinori Soejima1; Tetsuo Nonaka3; Toshiyuki
Okumura3; Hideyuki Sakurai3
1
Department of Radiation Oncology, Kobe Proton Center, Japan
2
Department of Anesthesiology, Kobe Proton Center, Japan
3
Department of Radiation Oncology, University of Tsukuba, Japan

*Corresponding Author(s): Nobuyoshi Fukumitsu, Abstract

Department of Radiation Oncology, Kobe Proton Center, Radiotherapy for liver cancers used to be palliative
1-6-8, Minatoshima Minamimachi, Chuoku, Kobe, Japan treatment. Currently, three-dimensional conformal
radiotherapy, stereotactic body radiotherapy, and particle
Tel: 81-78-335-8001, Fax: 881-78-335-8005, beam therapy using proton beams and carbon ion beams
Email: fukumitsun@yahoo.co.jp are used for the treatment of liver cancers. Radiotherapy for
liver cancers has become to curative treatment due to the
various technical progress. Radiotherapy can accomplish
safe and effective treatment for liver cancers.
Received: Mar 06, 2018
Accepted: May 10, 2018
Published Online: May 16, 2018
Journal: Annals of Gastroenterology and the Digestive System
Publisher: MedDocs Publishers LLC
Online edition: http://meddocsonline.org/
Copyright: © Fukumitsu N (2018). This Article is distributed
under the terms of Creative Commons Attribution 4.0
International License

Keywords: Liver cancer; Radiotherapy; Three-dimensional

conformal radiotherapy; Stereotactic body radiotherapy; Par-
ticle beam therapy

Three-dimensional conformal radiotherapy (3D-CRT)

Introduction
X-rays are usually used in 3D-CRT. Radiation is beamed from
Accurate localized diagnosis of liver cancers was difficult until
a direction perpendicular to the body axis in most cases; how-
the 1970s, and significance of radiotherapy for liver cancers is
ever it can be delivered from other directions by turning the
only palliative because it was difficult to suppress the damage
patients’ bed. One advantage of 3D-CRT is that it means the
to the radiosensitive liver. However, as Computed Tomography
shape of the irradiation field can be set 3-dimensionallyen-
(CT) became widespread for treatment planning in the1980s,
ablingdelivery of enough radiation to the target, accomplishing
the localized diagnosis of lesions became easy, therefore,
conformal beam irradiation to the target, while suppressing the
treatment could be performed while reducing liver damage.
irradiation dose to important tissue around the tumor. 3D-CRT
In recent years, radiotherapy is recognized to be one of the
is used in cases when other treatments are not available due to
curative treatment technique for liver cancers. Here we outline
Portal Vein Tumor Thrombosis (PVTT), unrespectability, or some
contemporary liver cancer radiotherapy.
complications.

Cite this article: Fukumitsu N, Mima M, Demizu Y, Suzuki T, Soejima T, et al. Development of radiotherapy for
liver cancer. Ann Gastroenterol Dig Syst. 2018; 1: 1005.

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A total irradiation dose around 45-50 Gyat a daily dose of 2 On the other hand, clinical history of radiotherapy for liver
Gyisoften reported. There have been many prospective studies cancer is at most 20-30 years. Thus, there is still no firm con-
in which the response rate was30-80% and the 1-year survival sensus about indications for this treatment. Although there are
rate was 25-50% for PVTT or for Inferior Vena Cava Thrombosis many reports about effectiveness and safety, they do not refer
(IVCT) patients [1-4]. Prospective and retrospective studies of to evidence-rich data for deciding the criteria for radiotherapy.
unrespectable cases have shown that the survival of patients More evidence-rich data is required in order to popularize ra-
who received Transarterial Chemoembolization (TACE) with ra- diotherapy for liver cancer to help these patients in future.
diotherapy was longer than patients who received only TACE,
and a meta-analysis study also proved higher response and Figures
survival rates in the TACE-with-radiotherapy group5.As for ad-
verse effects, it has been reported that radiotherapy can be per-
formed safely, with only elevation of the total bilirubin value in
many cases [5].
Stereotactic body radiotherapy (SBRT)
SBRT has a feature for treating small tumors. To condense
radiation and to hit the target accurately, it meets 3 criteria:
① higher dose to be delivered to a small target in a short term
from multiple directions using a linear accelerator, ② geo-
metrical accuracy finer than 5mm in every treatment session,
③ immobilizing the patient in position and countermeasures
for respiratory movement. Various device to fix the body and
highly accurate position matching system are required.
A total dose of 30-50 Gy at a daily dose of 6-15 Gy to the tu-
mor less than 5cm is usually performed. Even when the lesions
treated are difficult to cure by other local treatment, relatively
good outcomes are reported, such as a response rate of 50-85%,
Figure 1: Relative dose and depth (comparison of X-rays
1-year local control rate of 65-100%, 1-year overall survival rate
and particle beams).
50-90%, 2-year local control rate of 90-95% [6-10]. Serious liver
damage from the technique is very rare.
Particle beam therapy
Particle beam therapy uses high-energy protons carbon ions.
In contrast to X-rays, accelerated charged protons and carbon
ions release their maximum energy just before they stop, creat-
ing a steep peak of energy called the Bragg-peak. Furthermore,
regulating the dose distribution in the depth direction can be
accomplished by mixing different energy beams together, called
the spread-out Bragg peak. Figure 1 shows the concepts of X-
rays and particle beams and Figure 2 shows dose distribution
of proton beam therapy for liver cancers. Although the indica-
tion for treatment is similar to X-ray radiotherapy, particle beam
therapy can treat more advanced disease condition.
There are many reports of a total dose of radioactivity 60-
70 Gray Equivalent (GyE) at a daily dose of 2-6 GyE for proton
beam therapy. Dose escalation studies of carbon ion beam
therapy from 49.5 GyE to 79.5 GyE reveal that a total dose of 72
GyE at a daily dose of 4.8 GyEis ideal [11], and short term treat-
ment protocols, such as approximately 50 GyE in 1-2 weeks, is
also done. Many previous studies treated patients in Child-Pugh
classification A or B whom it was difficult to give other local
treatment [12-15,16]. In addition, PVTT, IVCT or a huge tumor
can be applied [17,18]. Excellent local control with extremely
rare adverse effects can be achieved.
Conclusion
Radiotherapy for liver cancer has been developed due to
technical progress such as the improvement of imaging, three-
dimensional treatment planning, reproducible irradiation tech- Figure 2: HCC patient. 63 years old man having HCC with
nique, and precise management of the irradiation treatment PVTT (Vp4). Complete response and re-canalization was seen
system. In the daily clinic, more number of patients has come 18 months after PBT (arrow).
to hospital to ask for radiotherapy.

Annals of Gastroenterology and the Digestive System 2


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